Cost of Cancer Care

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:07Welcome to Yale Cancer Answers with
00:07 --> 00:09your host, Doctor Anees Chagpar.
00:09 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care by
00:14 --> 00:15welcoming oncologists and specialists
00:15 --> 00:18who are on the forefront of the
00:18 --> 00:19battle to fight cancer. This week,
00:19 --> 00:21it's a conversation about the cost
00:21 --> 00:23of cancer care in the United States,
00:23 --> 00:25with Doctor Cary Gross and MD
00:25 --> 00:26PhD student Ryan Chow.
00:26 --> 00:28Doctor Gross is a professor of
00:28 --> 00:30medicine and of epidemiology
00:30 --> 00:32at the Yale School of Medicine,
00:32 --> 00:34where Doctor Chagpar is a
00:34 --> 00:36professor of surgical oncology.
00:37 --> 00:39Cary, maybe we'll start off with you.
00:39 --> 00:41Why don't you tell us a little bit more
00:41 --> 00:43about yourself and what it is you do.
00:43 --> 00:46I am a primary care doctor and a researcher
00:46 --> 00:49in the area of cancer outcomes
00:49 --> 00:51and cancer effectiveness research.
00:51 --> 00:54So I was a chief resident at a major
00:54 --> 00:57Cancer Center many years ago and was always,
00:57 --> 00:59always interested in primary care,
00:59 --> 01:02not necessarily in being an oncologist.
01:02 --> 01:05But while I was there at the Cancer Center,
01:05 --> 01:06I noticed that obviously
01:06 --> 01:09all of the patients had cancer.
01:09 --> 01:10I knew where I was,
01:10 --> 01:13but also many of the patients were being
01:13 --> 01:16admitted in the context of a clinical trial,
01:16 --> 01:20and I noticed that many of the patients
01:20 --> 01:24did not have other health problems.
01:24 --> 01:25Most of the patients had cancer,
01:25 --> 01:27but as a primary care DOC,
01:27 --> 01:28I was looking around and asking.
01:28 --> 01:30Geez, where are the patients
01:30 --> 01:32with diabetes and emphysema and?
01:32 --> 01:35Other chronic health health issues.
01:35 --> 01:35Similarly,
01:35 --> 01:37it just seemed as though many
01:37 --> 01:39of the patients who are aside
01:39 --> 01:40from their cancer are relatively
01:40 --> 01:42healthier and on the younger side,
01:42 --> 01:44you know, many of our patients were,
01:44 --> 01:45you know,
01:45 --> 01:485060 years old and bottom line
01:48 --> 01:50in the real world,
01:50 --> 01:53patients with cancer are are often older
01:53 --> 01:56and sicker than they are in in clinical
01:56 --> 01:59research studies and and that insight.
01:59 --> 02:01Which occurred to me over the
02:01 --> 02:02course of my clinical training
02:02 --> 02:04has really spurred the rest of my
02:04 --> 02:06research in the sense of trying
02:06 --> 02:08to understand what happens in the
02:08 --> 02:11real world when drugs or tests,
02:11 --> 02:12or, you know,
02:12 --> 02:14kind of imaging modalities such
02:14 --> 02:16as new mammograms or CAT scans,
02:16 --> 02:18or what have you.
02:18 --> 02:20What happens when things that look
02:20 --> 02:22like they are really potentially
02:22 --> 02:24groundbreaking and helpful in
02:24 --> 02:26the clinical trial setting?
02:26 --> 02:27What happens when they're actually
02:27 --> 02:28used in the real world?
02:29 --> 02:31Great and you know, Carrie and I
02:31 --> 02:33have been working together for a
02:33 --> 02:35number of years now and I know Kerry.
02:35 --> 02:38One of your particular interests
02:38 --> 02:41is in the value of cancer
02:41 --> 02:43care and cost effectiveness.
02:43 --> 02:47And are we really getting the bang
02:47 --> 02:50that we need for our buck and Ryan?
02:50 --> 02:52I guess this is where you come in.
02:52 --> 02:55Tell us a little bit more about yourself
02:55 --> 02:56and about how you met Carrie and
02:56 --> 02:58and a bit more about your research.
03:00 --> 03:02From MDP PhD student at Yale,
03:02 --> 03:04I actually did my PhD recently in
03:04 --> 03:06cancer genetics and tumor immunology,
03:06 --> 03:09but throughout the course of my
03:09 --> 03:11graduate education I kind of became
03:11 --> 03:12more interested in understanding
03:12 --> 03:15the economics of cancer care and
03:15 --> 03:17part of that stemmed from the
03:17 --> 03:19realization that a lot of these new
03:19 --> 03:20drugs that we're talking about,
03:20 --> 03:21like immunotherapies,
03:21 --> 03:24they have these incredibly large price tags,
03:24 --> 03:26and so I just got interested in understanding
03:26 --> 03:28we're paying so much for these drugs.
03:28 --> 03:30But how much benefit?
03:30 --> 03:32Patients actually getting from loan.
03:32 --> 03:34So I reached out to doctor Gross
03:34 --> 03:36because I knew of his work,
03:36 --> 03:37particularly with cancer outcome
03:37 --> 03:40research and economics of cancer care.
03:40 --> 03:41So yeah,
03:41 --> 03:42I just reached out to him and we started
03:42 --> 03:44working together on this project.
03:44 --> 03:46So Carrie, tell us a little bit more
03:46 --> 03:48about this recent project that just
03:48 --> 03:51got published and that really made
03:51 --> 03:53quite a quite a splash in terms of
03:53 --> 03:55raising awareness about the cost of
03:55 --> 03:57cancer care and and the relative
03:57 --> 04:00bang that you get for your buck.
04:00 --> 04:02Looks a bit more about the project,
04:02 --> 04:06sure, so you know, as Warren Buffett says,
04:06 --> 04:07Price is what you pay.
04:07 --> 04:11The value is what you get and you know
04:11 --> 04:15it's well known that the overall price
04:15 --> 04:17that we're paying for healthcare in
04:17 --> 04:19the United States is is exorbitant.
04:19 --> 04:21We're spending this for all care,
04:21 --> 04:23not just cancer care,
04:23 --> 04:25but we're spending over $4 trillion per year.
04:25 --> 04:28And in fact, our health expenses
04:28 --> 04:31are about 1/5 of our overall.
04:31 --> 04:32Gross domestic product.
04:32 --> 04:35So you know there's the old
04:35 --> 04:37saying that the what is it the
04:37 --> 04:39business of America is business.
04:39 --> 04:40You could almost say nowadays the
04:40 --> 04:42business of America is is healthcare.
04:42 --> 04:45I mean it's a it's our largest
04:45 --> 04:47industry and some by some measures.
04:47 --> 04:49So the question is when when we want to
04:49 --> 04:52focus on cancer for this particular study.
04:52 --> 04:54First we reached out to a
04:54 --> 04:56long term collaborator,
04:56 --> 04:57Doctor Elizabeth Bradley,
04:57 --> 05:01who is now actually President of Astra.
05:01 --> 05:01Knowledge,
05:01 --> 05:04but also as a health economist and
05:04 --> 05:07has a long interest and expertise in
05:07 --> 05:10international comparisons and and outcomes.
05:10 --> 05:13But we wanted to really explore
05:13 --> 05:15how much are we spending on
05:15 --> 05:17cancer care in the United States?
05:17 --> 05:19How does that compare to other countries?
05:19 --> 05:21And then that's the first half
05:21 --> 05:22of the Warren Buffett part.
05:22 --> 05:24How much are we spending?
05:24 --> 05:27But then more importantly, the value aspect.
05:27 --> 05:28What are we getting in return?
05:28 --> 05:30What were the?
05:30 --> 05:31How does.
05:31 --> 05:34Our cancer mortality and the population
05:34 --> 05:37level in the US compare to the cancer
05:37 --> 05:40mortality rates in other countries,
05:40 --> 05:43and so Ryan tell us a little bit more
05:43 --> 05:46about the design of this study and and
05:46 --> 05:48the the sources of data that you used.
05:49 --> 05:49Yeah, definitely.
05:49 --> 05:53So we were primarily interested in comparing
05:53 --> 05:56the US with other high income countries,
05:56 --> 05:58so first talking about cost.
05:58 --> 06:00So it turns out there are quite a few
06:00 --> 06:03organizations out there, such as the OCD.
06:03 --> 06:05Which stands for Organization for
06:05 --> 06:08Economic Cooperation and development,
06:08 --> 06:10and so there are these organizations
06:10 --> 06:11that track total healthcare
06:11 --> 06:13spending for different countries.
06:13 --> 06:15But as Doctor Gross was mentioning,
06:15 --> 06:17a lot of this data oftentimes
06:17 --> 06:19isn't cancer specific.
06:19 --> 06:21So to get to that question
06:21 --> 06:23of how much cancer care is,
06:23 --> 06:25you know how much countries
06:25 --> 06:26are spending on cancer care.
06:26 --> 06:28And we took a look through the literature.
06:28 --> 06:31We tried to find out in a given country what
06:31 --> 06:33percentage of their total health spending.
06:33 --> 06:35Goes towards cancer care.
06:35 --> 06:38So in the US it turns out we spend
06:38 --> 06:40around 5.3% of our total healthcare
06:40 --> 06:41spending on cancer,
06:41 --> 06:43but that varies quite a bit across country.
06:43 --> 06:45So in Japan that's actually
06:45 --> 06:477.5% towards cancer care.
06:47 --> 06:49So bringing those two numbers
06:49 --> 06:52together that allows us to estimate,
06:52 --> 06:53you know how many,
06:53 --> 06:56how much of our healthcare spending in the
06:56 --> 06:58given country is dedicated towards cancer.
06:58 --> 07:00So that's the cost part of it.
07:00 --> 07:01On the mortality side,
07:01 --> 07:03it's a little bit more complicated,
07:03 --> 07:06particularly because we're trying to compare
07:06 --> 07:09cancer outcomes across different countries.
07:09 --> 07:10So what I mean by that is,
07:10 --> 07:12clinicians will commonly refer
07:12 --> 07:14to five year survival rates
07:14 --> 07:16when their counseling patients.
07:16 --> 07:17That basically means the percentage
07:17 --> 07:19of patients that will still be
07:19 --> 07:21alive five years after an initial.
07:21 --> 07:21Diagnosis.
07:21 --> 07:24And so that's very useful, right?
07:24 --> 07:25It's great for informing
07:25 --> 07:27patients of their prognosis.
07:27 --> 07:28The problem,
07:28 --> 07:28though,
07:28 --> 07:30is that it's really difficult
07:30 --> 07:32to compare these five year
07:32 --> 07:33survival rates across countries,
07:33 --> 07:35and that's because different countries
07:35 --> 07:38have their own distinct approaches for
07:38 --> 07:40cancer detection and for screening.
07:40 --> 07:42So I guess it would be helpful to
07:42 --> 07:44give like an example for this,
07:44 --> 07:46but what I mean by this?
07:46 --> 07:48So let's say there's this rare
07:48 --> 07:50hypothetical disease that is untreatable
07:50 --> 07:52and all patients with this disease
07:52 --> 07:55will die when they turn 50 years old.
07:55 --> 07:57If a patient is diagnosed when they turn 40,
07:57 --> 07:59then we would look at that and say,
07:59 --> 08:01oh the survival time is 10 years.
08:01 --> 08:02But let's say we diagnose
08:02 --> 08:04this disease as a kid,
08:04 --> 08:06then the survival might look
08:06 --> 08:07something like 30 years instead.
08:07 --> 08:09But the key here is that the underlying
08:09 --> 08:11disease really hasn't changed.
08:11 --> 08:12All the only differences
08:12 --> 08:14when we diagnosed it.
08:14 --> 08:16So when we look at 5 year survival
08:16 --> 08:18rates across different countries,
08:18 --> 08:19a country that screens more
08:19 --> 08:21aggressively is going to detect
08:21 --> 08:24cancers earlier and that'll lead us
08:24 --> 08:25to artificially have higher five
08:25 --> 08:28year survival rates even though the
08:28 --> 08:29underlying disease is unchanged.
08:29 --> 08:32So instead of that in our study we
08:32 --> 08:34are looking at population level
08:34 --> 08:36cancer mortality rates and that
08:36 --> 08:37basically answers the question
08:37 --> 08:40in a given year how many people
08:40 --> 08:41are dying from cancer.
08:41 --> 08:43In a particular country,
08:43 --> 08:45so doctor Gross and I discussed
08:45 --> 08:47this quite extensively and
08:47 --> 08:49we we came to the conclusion that
08:49 --> 08:51this metric of population level,
08:51 --> 08:53cancer mortality is much better at
08:53 --> 08:55sort of encapsulating the effectiveness
08:55 --> 08:57of all these different cancer
08:57 --> 08:59related interventions that we have.
08:59 --> 09:01So you know, that would include prevention,
09:01 --> 09:04screening, and of course, treatment.
09:04 --> 09:08And so setting up now we have the costs.
09:08 --> 09:10How much do different countries spend on
09:10 --> 09:12cancer Care now we're looking at mortality.
09:12 --> 09:14What is the population level?
09:14 --> 09:15Cancer mortality rate that gave
09:15 --> 09:17us all the data that we needed to
09:17 --> 09:19start crunching the numbers and
09:19 --> 09:21taking a look at that relationship.
09:21 --> 09:22If there is any relationship
09:22 --> 09:23between those two numbers?
09:25 --> 09:27Very, you know, just digging into
09:27 --> 09:30that a little bit more deeply.
09:30 --> 09:33It's clear, right that the US spends more
09:33 --> 09:35on healthcare than any other country,
09:35 --> 09:37not only in the industrialized world,
09:37 --> 09:42but in the world period by by several.
09:42 --> 09:44By quite a magnitude.
09:44 --> 09:47And so it's not surprising to see
09:47 --> 09:49that they spend more on cancer care,
09:49 --> 09:52but the one thing that was interesting
09:52 --> 09:55in what Ryan was saying is that the
09:55 --> 09:57percentage of that total expenditure
09:57 --> 09:59of on healthcare that given countries
09:59 --> 10:02spend on cancer care may be different.
10:02 --> 10:04Can you talk a little bit about
10:04 --> 10:06how that fell when you compared
10:06 --> 10:08the US to other countries?
10:10 --> 10:10Interesting question,
10:10 --> 10:12and certainly something we want to
10:12 --> 10:14explore more and further research
10:14 --> 10:16because there was some variation in
10:16 --> 10:18how much of the overall health is being
10:18 --> 10:20spent on cancer care across countries,
10:20 --> 10:22but overall it was relatively stable
10:22 --> 10:24so there was there was some variation
10:24 --> 10:27and we expected to see some variation,
10:27 --> 10:30for instance because it's well known that
10:30 --> 10:33in the US we approve new cancer therapies
10:33 --> 10:35more quickly than in other countries.
10:35 --> 10:37Actually, there was just a study
10:37 --> 10:39published a couple of weeks ago comparing
10:39 --> 10:41the US and Europe and looking at.
10:41 --> 10:44How quickly a new drugs were approved
10:44 --> 10:45here as opposed to in Europe,
10:45 --> 10:47and there's actually about
10:47 --> 10:48a nine month delay,
10:48 --> 10:51so they're approved after FDA approval
10:51 --> 10:54of a new cancer therapy in the US,
10:54 --> 10:58average delay was about nine months before
10:58 --> 11:01typical European country had it approved.
11:01 --> 11:04But so they're so good,
11:04 --> 11:05but at least you know me so well,
11:05 --> 11:07but they're.
11:07 --> 11:12Isn't necessarily A cause for a victory lap,
11:12 --> 11:15but only if if the only evidence
11:15 --> 11:17of our systems efficacy is that
11:17 --> 11:19we're approving drugs more quickly.
11:19 --> 11:20So the real question is,
11:20 --> 11:22is whether patients are benefiting.
11:22 --> 11:27So we we expected there would be some
11:27 --> 11:30variation in the percent of overall
11:30 --> 11:32healthcare being spent on cancer,
11:32 --> 11:34primarily because we know that there's
11:34 --> 11:36variation across countries and how
11:36 --> 11:38quickly new drugs are being approved.
11:38 --> 11:40There's also variation in how
11:40 --> 11:42the different companies help us.
11:42 --> 11:45Sorry, different Freudian slip.
11:45 --> 11:47How different countries health
11:47 --> 11:50systems are established in the sense
11:50 --> 11:52of allowing them to negotiate with
11:52 --> 11:54pharmaceutical companies in the sense
11:54 --> 11:57that in the US there's not really
11:57 --> 11:59room for negotiation with with pharma
11:59 --> 12:03as opposed to in in other countries.
12:03 --> 12:07Coverage of new cancer therapies is
12:07 --> 12:11not necessarily mandated, for instance.
12:11 --> 12:14Certain National Health systems
12:14 --> 12:16could could just say no.
12:16 --> 12:19If a new therapy is not thought to be
12:19 --> 12:21producing high value for its population,
12:21 --> 12:24they may not cover it and that leverage
12:24 --> 12:26which does not exist in the US.
12:26 --> 12:29The leverage can allow for lower
12:29 --> 12:31prices in other countries.
12:31 --> 12:32So yeah,
12:32 --> 12:34that there's plenty of reasons for
12:34 --> 12:37variation in how much is being
12:37 --> 12:38spent on cancer.
12:38 --> 12:41But at the end of the day, we're actually.
12:41 --> 12:43A little surprised that there wasn't
12:43 --> 12:45as much variation in the percent of
12:45 --> 12:47healthcare on cancer as we thought
12:47 --> 12:48that we would,
12:48 --> 12:50and I think most of the variation
12:50 --> 12:53that we've seen in the overall cancer
12:53 --> 12:56spending probably relates strongly to
12:56 --> 12:59simply to the overall health spending.
13:00 --> 13:03And did you control for Ryan?
13:03 --> 13:06Did you control for the the fact
13:06 --> 13:08that different countries may
13:08 --> 13:11have a different cancer burden?
13:11 --> 13:14In other words, you would expect
13:14 --> 13:17that countries that have a higher.
13:17 --> 13:20Cancer burden who are diagnosing
13:20 --> 13:21patients more frequently with
13:21 --> 13:23cancer for whatever reason?
13:23 --> 13:25Whether it's you know.
13:25 --> 13:28Levels of obesity or smoking or
13:28 --> 13:30alcohol or other risk factors,
13:30 --> 13:33or whether there are particular genetic
13:33 --> 13:35predispositions in a given population.
13:35 --> 13:37Did you control for the incidence
13:37 --> 13:38of cancer across these countries?
13:39 --> 13:40Yeah, that's a great question.
13:40 --> 13:42Umm, that's also something Doctor Gross,
13:42 --> 13:43and I debated quite a bit
13:43 --> 13:45when we were starting out.
13:45 --> 13:47So in short, we looked at population
13:47 --> 13:50level cancer mortality rates rather
13:50 --> 13:51than adjusting for the incidence
13:51 --> 13:54of a given cancer because of that
13:54 --> 13:56reason I was discussing earlier
13:56 --> 13:58where countries that screen more
13:58 --> 14:00aggressively may be detecting cancers
14:00 --> 14:03that are indolent or not so aggressive.
14:03 --> 14:05So purely taking or adjusting for
14:05 --> 14:07the incidence of cancer across
14:07 --> 14:09countries was something that we felt.
14:09 --> 14:11That would introduce more bias
14:11 --> 14:12than we wanted,
14:12 --> 14:14and so we ultimately decided to purely
14:14 --> 14:16look at cancer mortality rates.
14:16 --> 14:17I will say, though,
14:17 --> 14:19that we did adjust for smoking
14:19 --> 14:21rates across different countries,
14:21 --> 14:23so countries that smoke less will have
14:23 --> 14:25lower cancer incidence and mortality
14:25 --> 14:27and so that it is something that we
14:27 --> 14:29try to adjust for within our study.
14:31 --> 14:33The thing that I was getting at
14:33 --> 14:35was really in terms of the cost.
14:35 --> 14:36The higher the incidence you
14:36 --> 14:38would expect that the higher the
14:38 --> 14:40proportion of the healthcare budget
14:40 --> 14:42would be going towards cancer.
14:42 --> 14:44We're going to have to pick up on
14:44 --> 14:46this conversation right after we take
14:46 --> 14:47a short break for a medical minute.
14:47 --> 14:49Please stay tuned to learn more about
14:49 --> 14:51the cost of cancer care and how that
14:51 --> 14:53relates to outcomes with my guests.
14:53 --> 14:55Doctor Terry Gross and Ryan Chow.
14:56 --> 14:58Funding for Yale Cancer Answers is
14:58 --> 15:00provided by Smilow Cancer Hospital,
15:00 --> 15:03where you can view videos from their
15:03 --> 15:05integrative medicine team by searching
15:05 --> 15:07Yale Cancer Center Integrative
15:07 --> 15:09Medicine playlist on YouTube.
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15:17 --> 15:18Completing treatment for cancer
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15:40 --> 15:43Resources for cancer survivors are
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16:09 --> 16:11listening to Connecticut.
16:11 --> 16:12Public radio.
16:12 --> 16:15Welcome back to Yale Cancer Answers.
16:15 --> 16:17This is doctor Anees Chagpar and I'm
16:17 --> 16:19joined tonight by my guests doctor
16:19 --> 16:22Cary Gross and Ryan Chow. We're talking
16:22 --> 16:25about the cost of cancer care in the US
16:25 --> 16:27and so right before the break we were
16:27 --> 16:30talking about the study that Cary
16:30 --> 16:32and Ryan just published recently
16:32 --> 16:35looking at the US healthcare
16:35 --> 16:38system compared to other high income
16:38 --> 16:40countries and the cost of care,
16:40 --> 16:42particularly the cost of cancer
16:42 --> 16:45care and how that really relates
16:45 --> 16:48to mortality.
16:48 --> 16:52Cary, in terms of the cost of care you
16:52 --> 16:55you're finding really was that the US
16:55 --> 16:58spends more per capita than any other
16:58 --> 17:00country on the face of the planet.
17:00 --> 17:03And when you multiply the proportion
17:03 --> 17:06of that overall healthcare budget
17:06 --> 17:08at times the proportion spent on
17:08 --> 17:11cancer care which was relatively
17:11 --> 17:13equal amongst all of the
17:13 --> 17:16countries that you compared the US
17:16 --> 17:18still spends more. Is that right?
17:18 --> 17:21Yeah, and quite a bit more so
17:21 --> 17:23we're spending about $200 billion
17:23 --> 17:26per year on cancer care in the US
17:26 --> 17:29and on the average per person.
17:29 --> 17:30That's not per person with cancer,
17:30 --> 17:32but just per person in the US.
17:32 --> 17:35You know that comes out to
17:35 --> 17:36around $600.00 per person.
17:36 --> 17:39We're spending on cancer care
17:39 --> 17:41and this compares to the average
17:41 --> 17:43amongst the other wealthy.
17:43 --> 17:45These are all wealthy,
17:45 --> 17:46industrialized countries in
17:46 --> 17:48the global global north.
17:48 --> 17:50In our sample the average
17:50 --> 17:52was about $300.00 per person
17:52 --> 17:53being spent on cancer care,
17:53 --> 17:56and some of these countries were
17:56 --> 17:58were down to 200 per person.
17:58 --> 17:59So when we're thinking about
17:59 --> 18:02the $200 billion per year being
18:02 --> 18:04spent on cancer in the US,
18:04 --> 18:07and the fact that that's you know three
18:07 --> 18:09times per capita seen in other countries,
18:09 --> 18:10it's also really important to
18:10 --> 18:12think about the experience of
18:12 --> 18:13patients with cancer and how.
18:13 --> 18:15For many of them,
18:15 --> 18:15they're struggling,
18:15 --> 18:17struggling to pay for these new therapies.
18:17 --> 18:18You know,
18:18 --> 18:22in some studies you know up to 1/4 of
18:22 --> 18:24patients with cancer are going into debt,
18:24 --> 18:27so but just to clarify that when
18:27 --> 18:31you talk about $600.00 per capita,
18:31 --> 18:332 questions, first of all,
18:33 --> 18:35that's an annual expense.
18:35 --> 18:42Correct? And 2nd, is that $600?
18:42 --> 18:46Borne by the healthcare system,
18:46 --> 18:47in other words,
18:47 --> 18:49is that the amount that the government
18:49 --> 18:51is paying out as part of Medicare,
18:51 --> 18:53or is that the total amount
18:53 --> 18:56in terms of what industry,
18:56 --> 18:58is paying what pharma is paying,
18:58 --> 19:00what hospitals are paying?
19:00 --> 19:01Or is it?
19:01 --> 19:03What individuals are paying,
19:03 --> 19:06and if it is the latter,
19:06 --> 19:08does it include all of the
19:08 --> 19:10ancillary costs so you know when
19:10 --> 19:12you think about healthcare costs?
19:12 --> 19:14Certainly there are the costs of your copays.
19:14 --> 19:15When you're deductibles,
19:15 --> 19:17but then there's also the other cost right?
19:17 --> 19:19The time off of work,
19:19 --> 19:21the childcare and and everything else.
19:21 --> 19:23So what really were the
19:23 --> 19:25costs that were looked at?
19:25 --> 19:27Yeah, that's a great question.
19:27 --> 19:30So for this study we focused on the big
19:30 --> 19:33picture of global cost of basically all
19:33 --> 19:36interactions with the healthcare system.
19:36 --> 19:38Whether somebody was Medicare,
19:38 --> 19:40Medicaid, private insurance.
19:40 --> 19:43But when somebody went and received some
19:43 --> 19:45form of care that relates to cancer.
19:45 --> 19:46What did the costs come out to?
19:46 --> 19:48And just to be clear,
19:48 --> 19:50that $600.00 per person that's not
19:50 --> 19:52$600.00 per patient with cancer.
19:52 --> 19:54That's $600.00 for each and every one
19:54 --> 19:57of the 300 million people in the US.
19:57 --> 20:00So everyone if you if you were to
20:00 --> 20:02spread out the the investment in
20:02 --> 20:05cancer across the entire population,
20:05 --> 20:06that's what it comes out to.
20:06 --> 20:08And as far as the yeah,
20:08 --> 20:10the time costs the out of pocket costs.
20:10 --> 20:12Saw one study that just published
20:12 --> 20:13a couple of years ago.
20:13 --> 20:15They estimated that the.
20:15 --> 20:17Out of pocket costs.
20:17 --> 20:20After insurance and everything
20:20 --> 20:23was covering as much as it could,
20:23 --> 20:26or over $16 billion per year for
20:26 --> 20:29patients with cancer and the same study
20:29 --> 20:31estimated the time cost with cancer,
20:31 --> 20:33meaning the cost of actually
20:33 --> 20:35going to and from treatments.
20:35 --> 20:38Cost of missed work, etcetera.
20:38 --> 20:39We're about 5 billion.
20:39 --> 20:40I think that's a gross
20:40 --> 20:42underestimate to be honest with you,
20:42 --> 20:45I think what we're not properly
20:45 --> 20:46understanding or measuring.
20:46 --> 20:49The the time cost that that that
20:49 --> 20:51takes to to deal with cancer.
20:52 --> 20:54And so you know, Ryan,
20:54 --> 20:56when we think about cost and we'll,
20:56 --> 20:57we'll get to benefits in a minute.
20:57 --> 21:00But I, I really want to dig into the
21:00 --> 21:02the cost side of things because I,
21:02 --> 21:04you know, there's a difference
21:04 --> 21:06between Kerry when you quoted,
21:06 --> 21:09I think you quoted it was $200 billion,
21:09 --> 21:11right? $600.00 per person spread
21:11 --> 21:13out over the population so you can
21:13 --> 21:15imagine for each cancer patient,
21:15 --> 21:18given the fact that cancer doesn't
21:18 --> 21:20affect every single individual
21:20 --> 21:22for a given cancer patient.
21:22 --> 21:24That $600.00 is probably
21:24 --> 21:28more like you know 2 grand.
21:28 --> 21:30When we think about the number of
21:30 --> 21:32people who get cancer in this country,
21:32 --> 21:35uh, individually, but so.
21:35 --> 21:37So the cost Ryan.
21:37 --> 21:40Just to clarify that is not just the out
21:40 --> 21:44of pocket cost for these individuals,
21:44 --> 21:46but it also includes the costs
21:46 --> 21:49that are borne by other sectors
21:49 --> 21:52of the healthcare system.
21:52 --> 21:53Is that right?
21:53 --> 21:55Or is it only the out of
21:55 --> 21:57pocket cost for individuals,
21:58 --> 22:00right? So it. It does reflect
22:00 --> 22:01the total healthcare spending,
22:01 --> 22:04not just out of pocket costs,
22:04 --> 22:05so that would include a lot
22:05 --> 22:07of these drugs do have some
22:07 --> 22:08degree of insurance coverage,
22:08 --> 22:11and so the total cost of those drugs is
22:11 --> 22:13factored into our our cost estimates,
22:13 --> 22:14not just what the patient
22:14 --> 22:16pays out of pocket. Yeah,
22:16 --> 22:18because certainly you know the
22:18 --> 22:20the insurance company has a cost
22:20 --> 22:22and and the patient not only
22:22 --> 22:24has their out of pocket costs,
22:24 --> 22:26but they also have their deductibles.
22:26 --> 22:28And so on and so forth, and so Carrie
22:28 --> 22:30before we transition back to Ryan.
22:30 --> 22:31Talk more about the benefits,
22:31 --> 22:33just to clarify as well,
22:33 --> 22:35this was not just about medications.
22:35 --> 22:37This was about hospital stays.
22:37 --> 22:40It was about surgeries.
22:40 --> 22:42It was about radiation treatments.
22:42 --> 22:45It was about was it about
22:45 --> 22:47things like physical therapy,
22:47 --> 22:48occupational therapy,
22:48 --> 22:51which are also often part of that
22:51 --> 22:52multidisciplinary cancer care.
22:54 --> 22:56Yeah, that's the key question
22:56 --> 22:58is what is the what are the
22:58 --> 23:00contributors to the overall cost
23:00 --> 23:02and the variation across countries?
23:03 --> 23:04And we're not able to answer that
23:04 --> 23:06in this study because we we focused
23:06 --> 23:07on the big picture. Overall,
23:07 --> 23:11how much is being spent on cancer care?
23:11 --> 23:13And one thing I've noticed over
23:13 --> 23:15the course of my career.
23:15 --> 23:17Well, a lot of finger pointing happens.
23:17 --> 23:19I've noticed that the Pharmaceutical
23:19 --> 23:21industry loves to point out that
23:21 --> 23:22how expensive hospitals are and
23:22 --> 23:24hospitals love to point out how much,
23:24 --> 23:26how expensive the drugs are
23:26 --> 23:28and then radiation oncologists.
23:28 --> 23:30They they compare their their cost to.
23:30 --> 23:32You know other non radiation treatments.
23:32 --> 23:35So I mean all of these different
23:35 --> 23:38components add up substantially and
23:38 --> 23:40they're each important contributors.
23:40 --> 23:43One thing I'm hoping is to a further
23:43 --> 23:46clarify how these vary across countries.
23:46 --> 23:49The different contributors to cancer costs,
23:49 --> 23:50but B.
23:50 --> 23:51Hopefully we'll one day be able
23:51 --> 23:54to get away from their finger
23:54 --> 23:56pointing idea because I think it's
23:56 --> 23:58very easy to point out how,
23:58 --> 24:00how important it is to look
24:00 --> 24:02for cost savings elsewhere,
24:02 --> 24:04and we could encourage more of
24:04 --> 24:05the different sectors to roll up
24:05 --> 24:07their sleeves and try to dial
24:07 --> 24:09down costs in their own areas.
24:10 --> 24:12And so Ryan, you know.
24:12 --> 24:13Transitioning now to really
24:13 --> 24:15thinking about the benefits,
24:15 --> 24:17we know that the US spends.
24:17 --> 24:19An inordinate amount of money on
24:19 --> 24:21health care and and proportionately
24:21 --> 24:23an inordinate amount on cancer care.
24:23 --> 24:26So what did you find in terms
24:26 --> 24:28of the actual benefit our,
24:28 --> 24:31our, our outcomes in the US,
24:31 --> 24:33substantially better than
24:33 --> 24:36other high income countries?
24:36 --> 24:38So the short answer is no,
24:38 --> 24:41the US is not necessarily doing that much
24:41 --> 24:43better than other high income countries.
24:43 --> 24:45So to give you more of the the
24:45 --> 24:47data behind that, so across these.
24:47 --> 24:48Income countries that we looked at,
24:48 --> 24:52the median mortality rate is about 91 deaths
24:52 --> 24:55from cancer per 100,000 people in a year,
24:55 --> 24:56and so in the US,
24:56 --> 25:00that was 86 deaths from cancer per 100,000,
25:00 --> 25:02and so that put the US at about
25:02 --> 25:04seventh lowest out of 22 countries.
25:04 --> 25:08So it's doing better than the median country.
25:08 --> 25:10But there is a caveat here and
25:10 --> 25:11that has to do with smoking.
25:11 --> 25:13So as I mentioned,
25:13 --> 25:14smoking is a major risk
25:14 --> 25:16factor for cancer mortality,
25:16 --> 25:17and this is an area that the US has
25:17 --> 25:18actually done a really good job.
25:18 --> 25:19And historically,
25:19 --> 25:22where the US smoking rate is much lower
25:22 --> 25:24than a lot of other industrialized nations,
25:24 --> 25:26and so if we account for that variation
25:26 --> 25:28in smoking rates across countries,
25:28 --> 25:30we actually find that the US cancer
25:30 --> 25:32mortality rate is then only tenth lowest,
25:32 --> 25:35and it's actually pretty much comparable
25:35 --> 25:37to the median high high income country.
25:37 --> 25:39So bringing together what we are
25:39 --> 25:41talking about with costs and
25:41 --> 25:42now thinking about mortality.
25:42 --> 25:45US spending twice as much on cancer
25:45 --> 25:47care as the average high income country.
25:47 --> 25:48But you know,
25:48 --> 25:50cancer mortality rates in the US are
25:50 --> 25:53pretty basically comparable to the average,
25:53 --> 25:55so that tells us that you know there
25:55 --> 25:57are still a lot of opportunities in
25:57 --> 25:59areas for improving the US cancer
25:59 --> 26:01care ecosystem that can really help
26:01 --> 26:02patients live longer and better,
26:02 --> 26:04and ideally at a more affordable
26:04 --> 26:05price as well.
26:06 --> 26:09Cary, then the obvious question,
26:09 --> 26:13right is who was the winner in terms of
26:13 --> 26:14outcomes versus cost?
26:16 --> 26:19So yeah, there are several in that domain.
26:19 --> 26:22Korea, Finland, Iceland,
26:22 --> 26:24Spain, Sweden. You know,
26:24 --> 26:26countries with National Health systems,
26:26 --> 26:29countries that have good,
26:29 --> 26:33you know prevention and screening efforts,
26:33 --> 26:34but also some of these countries
26:34 --> 26:36that they might have had.
26:36 --> 26:38Some of them have higher smoking
26:38 --> 26:40rates than the US, and you know,
26:40 --> 26:42many of these countries benefited from
26:42 --> 26:44the fact that the US has such a robust.
26:44 --> 26:47Research, infrastructure and and many of
26:47 --> 26:50the new cancer treatments used across
26:50 --> 26:53the world are generated in the US.
26:53 --> 26:56So you know by these important metrics.
26:56 --> 26:58Looking at cost and survival,
26:58 --> 26:59there are several countries
26:59 --> 27:00that are doing better,
27:00 --> 27:01but also it's important to
27:01 --> 27:03understand what we're doing so well.
27:03 --> 27:04Here you know what we are.
27:04 --> 27:06We have a low smoking rates.
27:06 --> 27:08We have excellent Cancer Research.
27:08 --> 27:12We have good cancer screening rates,
27:12 --> 27:15so I think we can all learn from.
27:15 --> 27:16Well,
27:16 --> 27:18each other countries are doing and you
27:18 --> 27:21know I'm just concerned that some to
27:21 --> 27:23be honest and I haven't said this yet.
27:23 --> 27:26The the origin of this particular
27:26 --> 27:28study is from dates back to a
27:28 --> 27:30different study that was roughly
27:30 --> 27:3310 years ago that was just a very
27:33 --> 27:35Pollyannaish study that looked at
27:35 --> 27:37survival after a cancer diagnosis
27:37 --> 27:39and Ryan described earlier why that
27:39 --> 27:41can be problematic that you know,
27:41 --> 27:43some countries have higher cancer
27:43 --> 27:45screening rates than others.
27:45 --> 27:47That, uh, it could be deceptive.
27:47 --> 27:49It could make it look like maybe
27:49 --> 27:50you have better cancer outcomes,
27:50 --> 27:53but this old study looked at cancer
27:53 --> 27:55survival rates and and said that the US
27:55 --> 27:58was doing better than everybody else.
27:58 --> 28:00So the higher costs are worth it.
28:00 --> 28:01And as you know,
28:01 --> 28:03they all this data kept coming in
28:03 --> 28:05about financial toxicity and concerns
28:05 --> 28:07about whether drugs are effective in
28:07 --> 28:10the real world as they were in the
28:10 --> 28:12initial studies and other studies coming in,
28:12 --> 28:14showing that maybe other
28:14 --> 28:15countries are doing better.
28:15 --> 28:17With their population level,
28:17 --> 28:19mortality really just kept driving
28:19 --> 28:21home this question that we have to
28:21 --> 28:24really learn from from different
28:24 --> 28:27national approaches to to healthcare,
28:27 --> 28:29to Wellness and to, you know,
28:29 --> 28:29payment reform.
28:30 --> 28:32Doctor Cary Gross is a professor
28:32 --> 28:34of medicine and of epidemiology,
28:34 --> 28:36and Ryan Chow is an MD PhD student
28:36 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public
28:55 --> 28:57radio. Funding for Yale Cancer Answers
28:57 --> 29:00is provided by Smilow Cancer Hospital.

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July 17, 2022

Yale Cancer Center

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